New Client Form

Please fill out this form prior to your first session.

(We recommend filling out this form on a desktop computer.)

Health and Well Being History Form

Part 1

Please answer the following questions honestly and to the best of your ability

This work treats you on all levels--mental, emotional, physical and spiritual. What are your goals from this work? What would you like to change or make possible?Describe the problem(s) for which you seek help. Please include dates when each problem occurred:Past medical history (previous injuries, accidents, surgeries, etc. Please describe and include approximate dates:List the medications (including over the counter) you are presently taking:What daily activities are you finding difficult or are limited because of your above complaints:
Have you ever had this problem before?NoYes

When?

Please list any other kind of healthcare professional you are seeing for this/these problem(s):Please list any medical tests you have had within the past year:

Part 2

Please mark what best describes the frequency with which you experience the below conditions.